Patient forms

Please fill in all fields marked with *

Personal details

Patient’s name*

Address

Postcode

Gender
Male Female

Pregnancy
Yes No Not Applicable

Date of birth

Email*

Phone*

Payee’s name (person responsible for payment of account)*

Payee’s number*

Payee’s address*

Do you have a Private Health Fund? If yes, what is the name of insurance company?

Dentist’s name*

Medical history

Does the patient have a health problem? If yes, please list

Is there a history of serious illness, accident or operation? If yes, please list

Is the patient under a doctor’s care for any problem at this time? If yes, please list

Is the patient taking any medication? If yes, please list

Does the patient have any allergies or drug sensitivities? If yes, please list

Dental history

Has the patient had an orthodontic consultation previously?
Yes No

Has the patient had any previous orthodontic treatment?
Yes No

Has the patient had any injury to the teeth? Y / N (this includes both baby & permanent teeth)
Yes No

Has the patient had any injury to the face, jaw or gums?
Yes No

Has the patient had any cysts or tumours of the jaws or gums?
Yes No

Have you been informed of any missing or extra permanent teeth?
Yes No

Does the patient suck fingers or thumb, or have a similar habit?
Yes No

Date of last dental examination

Reason for seeking orthodontic treatment

Medical checklist

How did you find out about us?*

Date:

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Personal medical information

Personal details

Medical history

Dental history

Medical checklist

Book a free Invisalign consultation

Which braces to
choose?

See the smiles we have transformed

Auckland Orthodontics

Personal medical information

Personal details

Medical history

Dental history

Medical checklist

Book a free Invisalign consultation

Which braces to choose?

See the smiles we have transformed

Patient forms

Auckland Orthodontics

Which braces to
choose?